Researchers in Uganda have examined why projects to increase women’s access to health services are difficult to sustain. They set out to look at the root causes of the lack of access to maternal health services and focused on gender dynamics. The maternal mortality rate in Uganda is high (around 400 per 100,000 live births), due in part to lack of access to maternal health care.
The researchers conclude: “in order to effectively address gendered inequities affecting women’s lack of maternal health care access and utilisation, gender must be integrated into the design, implementation, and evaluation of interventions.” They commend “gender transformative” approaches that directly address gender norms, address both how services are delivered (supply side) and working with men and women in the community (demand side).
The researchers organised group discussions involving mothers and fathers of babies (in separate groups), as well as transport drivers. The group discussions took place in a rural area in Eastern Uganda, characterised by subsistence farming and very low income.
Poverty emerged as a key problem, because attending clinics requires families to finance their own supplies and transport. Some mothers blamed fathers for not wanting to buy items, whilst some fathers argued that there simply was not any money for these things. One mother said, “husbands don’t want to buy items [for delivery] because they don’t care about their women.” One father said, “a woman may demand for many things which cannot be met”. Because of men’s provider role, if they choose not to provide for the woman, the woman has little alternative. Nevertheless, in both groups mothers and fathers identified cases where fathers did ensure that all necessary supplies and transportation were provided for.
A gendered division of labour is another key problem, with an expectation that women continue with housework irrespective of their pregnancy. One woman said, “[there is] too much work during pregnancy, women are not usually assisted by their husbands to do our work like cooking, washing, fetching water.”
Lack of involvement of some expectant fathers at health facilities was identified as an additional barrier, because in Uganda women accompanied by husbands are often seen first by staff. Fathers who did not attend facilities gave as reasons fear of being tested for HIV, having drinking problems, not knowing the significance of attending maternity health services, poor attitudes of health staff and the reluctance of their pregnant partners about them being present. In other research projects, other reported barriers to attending health facilities are work commitments and possible loss of income through attending.
Both mothers and fathers referred to rude and abusive behaviour by health workers at antenatal clinics. Some mothers and fathers were critical of each other in the discussions. Some fathers accused women of being aggressive, quarrelsome, lazy, extravagant, rude and dirty. Some mothers accused husbands of abandoning them and leaving childcare entirely to women. Domestic violence emerged as an issue in the women’s groups.
The researchers make one suggestion for transforming gender roles – empowering men to contribute to and/or share household work. In the next article, the Family Included team will respond to this with a different proposal for how to organise a gender transformative approach that will effectively engage men, based on a different global field of practice, father engagement.
Morgan R, Tetui M, Kananura RM, Ekirapa-Kiracho E & George AS (2017), Gender dynamics affecting maternal health and health care access and use in Uganda, Health Policy and Planning 32
Photo: Direct Relief. Creative Commons.